A nurse is caring for a patient immediately following endotracheal intubation.

Which of the following actions should the nurse prioritize to assess the patient for complications?

Auscultate lungs for the presence of breath sounds.

Determine that the pulse oximetry is greater than 95%.

Assess baseline level of consciousness.

Assess for the presence of circumoral cyanosis.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Auscultating the lungs for the presence of breath sounds is a priority action following endotracheal intubation. This helps to confirm correct tube placement and assess for complications such as a pneumothorax.
Choice B rationale
While it is important to ensure that the pulse oximetry is greater than 95% to confirm adequate oxygenation, this is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.
Choice C rationale
Assessing the baseline level of consciousness is important, but it is not the priority action following endotracheal intubation.
Choice D rationale
Assessing for the presence of circumoral cyanosis can indicate hypoxia, but it is not the priority action. The nurse should first confirm correct tube placement by auscultating lung sounds.

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Correct Answer is ["A","B","D"]

Explanation

Choice A rationale
Implementing ventilator-weaning protocols is a crucial intervention in the care plan for a patient on a ventilator to prevent ventilator-associated pneumonia. These protocols aim to minimize the patient’s exposure to mechanical ventilation, which is a significant risk factor for developing ventilator-associated pneumonia. By systematically reducing the level of ventilatory support, these protocols facilitate the earliest possible liberation from mechanical ventilation, thereby reducing the risk of ventilator-associated pneumonia.
Choice B rationale
Providing frequent oral care is another essential intervention in preventing ventilator- associated pneumonia. Oral health can quickly deteriorate in mechanically ventilated patients, leading to an increased risk of ventilator-associated pneumonia. Regular oral care, including the use of antiseptics, can help reduce the number of potential respiratory pathogens in the oral cavity and prevent their aspiration into the lower respiratory tract.
Choice C rationale
Suctioning the patient every hour is not typically recommended as a standard intervention to prevent ventilator-associated pneumonia. Over-suctioning can lead to trauma and inflammation in the airway, potentially increasing the risk of infection. Suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.
Choice D rationale
Positioning the patient in a semi-upright position (30 to 45 degrees), rather than a prone position, is recommended to prevent ventilator-associated pneumonia. This position helps to reduce the risk of aspiration, which is a major risk factor for ventilator-associated pneumonia.
Choice E rationale
Avoiding suctioning the patient is not a recommended strategy for preventing ventilator- associated pneumonia. Suctioning is necessary to clear secretions from the airway, and its omission could potentially increase the risk of infection. However, as mentioned earlier, suctioning should be performed based on the patient’s needs and clinical signs, rather than on a fixed schedule.

A. Client uses chewing tobacco every day. B. Client is an industrial-commercial painter. C. Client is an ultrasound technician. D. Client wears magnetic healing bracelets. E. Client’s husband smokes cigarettes.

Correct Answer is ["A","B","E"]

Explanation

Choice A rationale
Using chewing tobacco every day is a significant risk factor for laryngeal cancer. Tobacco contains many carcinogens, which can damage the cells in the larynx and lead to cancer.
Choice B rationale
Being an industrial-commercial painter is associated with an increased risk of laryngeal cancer. This is likely due to exposure to certain chemicals and toxins that are used in paints and other materials.
Choice C rationale
Being an ultrasound technician is not typically associated with an increased risk of laryngeal cancer. Ultrasound technicians are not generally exposed to the types of toxins or risk factors that are associated with laryngeal cancer.
Choice D rationale
Wearing magnetic healing bracelets is not associated with an increased risk of laryngeal cancer. There is no scientific evidence to suggest that these bracelets have any effect on cancer risk.
Choice E rationale
Having a spouse who smokes cigarettes is a risk factor for laryngeal cancer. Secondhand smoke, also known as passive smoke, contains many of the same carcinogens as the smoke inhaled by smokers. Exposure to secondhand smoke can increase a person’s risk of developing laryngeal cancer.

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A nurse is caring for a patient immediately following endotracheal intubation. Which of the following actions should the nurse prioritize to assess the patient for complications?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In the context of developing a care plan for a patient on a ventilator to prevent ventilator-associated pneumonia, which interventions should be included? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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A nurse is caring for a patient immediately following endotracheal intubation.

Which of the following actions should the nurse prioritize to assess the patient for complications?